Electrocardiographic abnormalities are prognostic of the clinical outcomes and mortality of patients with subarachnoid hemorrhages

PURPOSE

We explored the relationships between electrocardiographic (ECG) abnormalities and the clinical outcomes and mortality of patients with non-traumatic aneurysmal subarachnoid hemorrhages (SAHs).

METHODS

This retrospective cohort study enrolled consecutive adult patients who presented to emergency departments with non-traumatic aneurysmal SAHs. We recorded their demographics, clinical characteristics, and ECG findings, and explored the relationships between ECG abnormalities, on the one hand, and 28-day mortality and prognosis, on the other.

RESULTS

We enrolled 158 patients, 76 females (48.10%) and 82 males (51.90%) of average age 54.70 ± 7.07 years. A total of 107 patients (67.72%) exhibited at least one ECG abnormality, most commonly a T-wave change (n = 54, 34.18%). Such patients evidenced significantly higher Hunt-Hess and Fisher scale scores than those without abnormalities (both p < 0.001). Patients with abnormal ECG findings experienced more unfavorable outcomes and higher mortality than others (both p < 0.001). ECG abnormalities, including PR prolongation, pathological Q waves, QRS widening, left bundle branch blocks, premature ventricular contractions, ST segment changes, and T-wave changes, were more common in non-survivors and patients with Hunt-Hess scores of 4-5 compared to survivors and those with Hunt-Hess scores <4, respectively. Moreover, increased age and presence of abnormal ECG findings were independent predictors of mortality in aneurysmal SAHs.

CONCLUSIONS

Patients with abnormal ECG findings exhibited unfavorable clinical outcomes and increased mortality rates. Abnormal ECG findings combined with higher Hunt-Hess or Fischer grade scores usefully predict adverse clinical outcomes in and mortality of SAH patients.

Prevalence of Frailty in European Emergency Departments (FEED): an international flash mob study

INTRODUCTION

Current emergency care systems are not optimized to respond to multiple and complex problems associated with frailty. Services may require reconfiguration to effectively deliver comprehensive frailty care, yet its prevalence and variation are poorly understood. This study primarily determined the prevalence of frailty among older people attending emergency care.

METHODS

This cross-sectional study used a flash mob approach to collect observational European emergency care data over a 24-h period (04 July 2023). Sites were identified through the European Task Force for Geriatric Emergency Medicine collaboration and social media. Data were collected for all individuals aged 65 + who attended emergency care, and for all adults aged 18 + at a subset of sites. Variables included demographics, Clinical Frailty Scale (CFS), vital signs, and disposition. European and national frailty prevalence was determined with proportions with each CFS level and with dichotomized CFS 5 + (mild or more severe frailty).

RESULTS

Sixty-two sites in fourteen European countries recruited five thousand seven hundred eighty-five individuals. 40% of 3479 older people had at least mild frailty, with countries ranging from 26 to 51%. They had median age 77 (IQR, 13) years and 53% were female. Across 22 sites observing all adult attenders, older people living with frailty comprised 14%.

CONCLUSION

40% of older people using European emergency care had CFS 5 + . Frailty prevalence varied widely among European care systems. These differences likely reflected entrance selection and provide windows of opportunity for system configuration and workforce planning.

Intradermal Sterile Water Injection: Safe and Effective Alternative for Relief of Acute Renal Colic in the Emergency Department

BACKGROUND

The optimal pain relief method for acute renal colic in the emergency department remains controversial.

OBJECTIVE

We compared the safety and efficacy of intradermal sterile water injection (ISWI) to treatment with intramuscular (IM) diclofenac, intravenous (IV) opioids, and IV paracetamol in patients with acute renal colic.

METHODS

This randomized, single-blind study included 320 patients with renal colic to one of four treatment groups. The first group received ISWI at four different points around the most painful flank area. Patients in the DI, PARA, and TRAM groups received 75 mg IM diclofenac, 1 g IV paracetamol, and 100 mg IV tramadol, respectively. Pain intensity was measured using a visual analog scale (VAS) before treatment and 15, 30, and 60 min after treatment.

RESULTS

VAS scores 15 and 30 min after treatment were significantly lower in group ISWI than in groups DI, PARA, and TRAM. However, there were no significant differences in the decrease in the pain score at baseline and at 60 min after treatment. In addition, fewer patients required rescue analgesia in group ISWI than in group TRAM. However, no significant differences were observed between group ISWI and group DI or PARA in terms of the need for rescue analgesia. Finally, there were significantly fewer adverse events in group ISWI than in groups DI and TRAM.

CONCLUSIONS

ISWI had similar efficacy, faster pain relief, and lower need for rescue analgesia compared with diclofenac, paracetamol, and tramadol for the management of acute renal colic. In addition, ISWI was well-tolerated and had no adverse effects.

Analysis of Age-Specific Predictors of Mortality in Patients with Coronavirus Disease 2019

AIM

We investigated predictors of mortality, including demographic, clinical, and laboratory parameters, in hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia.

PATIENTS AND METHODS

This retrospective, single-center study included 651 consecutive Turkish adults who had been admitted to the emergency department with a diagnosis of COVID-19. We recorded the demographic, clinical, and laboratory parameters of the patients. The patients were divided into two groups: patients aged ≥65 years and patients aged <65 years. The predictors of mortality for hospitalized COVID-19 patients were evaluated.

RESULTS

The study included 651 patients (354 [54.4%] men and 297 [45.6%] women; mean age, 56.40 ± 15.70 years). The most common comorbidities were hypertension (37.6%), diabetes mellitus (28.9%), and coronary artery disease (CAD) (16.1%). The overall mortality rate was 10.6% (n = 69); the mortality rate was higher in men than in women. Advanced age; chronic renal failure (CRF); prolonged activated partial thromboplastin time; high serum neutrophil and platelet counts; high C-reactive protein to albumin (CRP/albumin) ratio; and high levels of albumin, lactate dehydrogenase (LDH), and high-sensitivity troponin I (TnI-hs) were independent predictors of mortality in all age groups.

CONCLUSION

Multivariate logistic regression analysis showed that chronic obstructive pulmonary disease (COPD), high serum platelet count, high CRP/albumin ratio, and high levels of albumin, TnI-hs, and D-dimer were independent predictors of mortality in patients aged <65 years. Conversely, advanced age, CAD, CRF, and high levels of serum CRP and LDH were independent predictors of mortality in patients aged ≥65 years.

Suicide attempts and the factors that lead to suicidal ideation: A 3-year analysis

OBJECTIVE

We explored the epidemiological characteristics of suicide attempts and identified suicide trends and associated factors.

METHODS

This retrospective, cross-sectional, observational, and single-center study included consecutive 412 patients who were admitted to Emergency Department for follow-up and treatment after a suicide attempt between June 2019 and June 2022. We assessed patient demographics, suicidal behavior, previous suicide attempts, psychiatric disorders, drug use, visits to the psychiatry clinic within the past 6 months, the persistence of suicidal ideation, and clinical outcomes.

RESULTS

The study population consisted of 259 females (62.86%) and 153 males (37.14%), with a mean age of 29.50±11.51 (range: 13-72) years. Females attempted suicide more often than males, but suicide completion was more common in males. Overall, 79.37% (n=327) of the suicide attempters were aged <40 years and most were 20-29 years old (n=147, 35.68%). Non-fatal suicide attempts were more common in single, unemployed, and poorly educated individuals, but this was not the case for suicide completers. However, there was no significant difference in marital status, education, and occupation among suicide completers. Drug poisoning was the major form of suicide attempt (n=345, 83.74%). Mental disorders, family or relationship conflicts, and separation from a partner were common causes of suicidal ideation. Patient numbers were particularly high in the autumn (i.e., September), and at night.

CONCLUSION

Females, young adults, singletons, the unemployed, and individuals with psychiatric disorders and low education levels are more likely to attempt suicide, particularly during hours when they are likely to be alone.

Evaluation of the trauma-specific frailty index in geriatric trauma patients according to the new World Health Organization age classification

OBJECTIVE

We compared the 15-variable trauma-specific frailty index and traditional injury scoring systems to determine trauma severity and predict discharge disposition in geriatric trauma patients based on the old and new World Health Organization age classifications.

METHODS

This prospective, observational, single-center study included geriatric patients aged ≥65 years with blunt trauma. We categorized patients as elderly based on the old or new World Health Organization age classification into group I (aged 65-79 years) and group II (aged ≥a80 years), respectively. At admission, we used traditional injury scoring systems (e.g., the Glasgow coma scale, injury severity score, and revised trauma score) to determine trauma severity. We compared the Trauma-Specific Frailty Index and traditional injury scoring systems between the patient groups and evaluated them for correlations.

RESULTS

We included 169 geriatric patients (80 and 89 in groups I and II, respectively). The mean Trauma-Specific Frailty Index score was significantly higher among females than males (p=0.025) and group II than group I (p=0.021). No significant correlations were observed in terms of the Trauma-Specific Frailty Index and traditional injury scoring systems in both groups. The mean Trauma-Specific Frailty Index score was significantly different between the hospitalized and discharged patients in group I (p=0.005), but not in group II (p=0.526).

CONCLUSION

The 15-variable Trauma-Specific Frailty Index score is superior to traditional injury scoring systems for managing and predicting discharge disposition in geriatric trauma patients aged 65-79 years.

Systemic inflammatory markers for distinguishing uncomplicated and complicated acute appendicitis in adult patients

OBJECTIVE

This study aimed to investigate the predictive power of serum systemic inflammatory markers including neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-eosinophil ratio (MER), and C-reactive protein (CRP) levels for distinguishing uncomplicated and complicated acute appendicitis in adult patients admitted to the emergency department (ED).

METHODS

This retrospective, cross-sectional, observational, and single-center study enrolled 212 consecutive adult patients with acute appendicitis who were admitted to the ED of our tertiary care university hospital between January 1, 2019 and December 31 2021. Patients were divided into two groups (Group I, uncomplicated acute appendicitis; Group II, complicated appendicitis) according to their surgical findings and histopathological examination. Systemic inflammatory markers measured on admission were compared among patients to identify factors associated with complicated acute appendicitis.

RESULTS

A total of 132 patients, 83 male (62.9%) and 49 female (37.1%), were included in the study. The mean age was 34.7±13.40 years. Based on the histopathological examination, the number of patients in Group I was 103 (78.03%) and 29 (21.96%) in Group II. Laboratory findings on admission revealed no significant differences between Groups I and II patients in terms of mean serum NLR, MER, and CRP values (p=0.096, p=0.248, and p=0.297, respectively). However, the mean serum PLR in Group II patients was statistically significantly higher than those in Group I (p=0.032). The mean serum monocyte and monocyte fraction (%) values were significantly lower, and the mean serum neutrophil fraction (%) value was higher in Group II patients compared to those with Group I. Receiving operator characteristic (ROC) analysis identified a serum PLR cutoff value of ≥133.73 for distinguishing uncomplicated and complicated acute appendicitis in adult patients, with 60% sensitivity and 58.4% specificity. In addition, ROC analysis revealed a cutoff monocyte fraction (%) level of ≤6, with 72% sensitivity and 64% specificity, for distinguishing uncomplicated and complicated acute appendicitis in adult patients.

CONCLUSION

Our findings indicate that the mean serum NLR, MER, and CRP values measured on admission to ED in adult patients with acute appendicitis could not predict complicated acute appendicitis. However, mean serum PLR and neutrophil and monocyte counts can be useful in distinguishing complicated cases.

The impact of meteorological factors on the spread of COVID-19

Background

Clinical studies suggest that warmer climates slow the spread of viral infections. In addition, exposure to cold weakens human immunity.

Aim

This study describes the relationship between meteorological indicators, the number of cases, and mortality in patients with confirmed coronavirus disease 2019 (COVID-19).

Patients and Methods

This was a retrospective observational study. Adult patients who presented to the emergency department with confirmed COVID-19 were included in the study. Meteorological data [mean temperature, minimum (min) temperature, maximum (max) temperature, relative humidity, and wind speed] for the city of Istanbul were collected from the Istanbul Meteorology 1^st Regional Directorate.

Results

The study population consisted of 169,058 patients. The highest number of patients were admitted in December (n = 21,610) and the highest number of deaths (n = 46) occurred in November. In a correlation analysis, a statistically significant, negative correlation was found between the number of COVID-19 patients and mean temperature (rho = -0.734, P < 0.001), max temperature (rho = -0.696, P < 0.001) or min temperature (rho = -0.748, P < 0.001). Besides, the total number of patients correlated significantly and positively with the mean relative humidity (rho = 0.399 and P = 0.012). The correlation analysis also showed a significant negative relationship between the mean, maximum, and min temperatures and the number of deaths and mortality.

Conclusion

Our results indicate an increased number of COVID-19 cases during the 39-week study period when the mean, max, and min temperatures were consistently low and the mean relative humidity was consistently high.

International Smuggling of Illicit Drugs by Body Concealment at a Tertiary Hospital in Istanbul

ABSTRACT

Smuggling of illicit substances by internal concealment has recently become a preferred method of international drug trade. The drug carriers are known as body packers. This study aimed to assess the demographic features and outcomes of body packers admitted to a referral center in Istanbul. Data were retrospectively evaluated from January 2017 to December 2019 from suspected body packers who were referred to the emergency department of a tertiary-care university by Istanbul Airport narcotics police due to suspected concealment of illicit drugs. Eighty-one cases were identified and included in this study. Of these, 71 subjects were confirmed to be body packers by radiological methods. The 15 women and 56 men had a mean age of 35 years. The most common nationality of the body packers was Nigerian, followed by Turkish and South African. Cocaine was the most commonly smuggled packet, followed by hashish, and heroin. All body packers were conservatively managed using laxatives or watchful waiting. No cases required surgical retrieval of packets. Abdominal radiography and computed tomography are useful tools for the evaluation of suspected body packers. The use of improved packaging material by smugglers and complications due to surgery and endoscopy make the conservative approach preferred.

Predictors of mortality in patients less than 50 years old with coronavirus disease 2019: a multicenter experience in Istanbul

OBJECTIVE

The objectives of this study were to identify predictors of mortality in young adult patients with coronavirus disease 2019 and to assess the link between blood type and mortality in those patients.

METHODS

This multicenter retrospective study, which was conducted in seven training and research hospitals in Istanbul, involved young adults who aged ≥18 and <50 years and hospitalized with coronavirus disease 2019.

RESULTS

Among 1,120 patients, confusion at admission (p<0.001) and oxygen saturation (p<0.001) were significantly predictive factors of mortality. Blood type O was significantly associated with mortality compared to those discharged from the hospital (p<0.001). Among co-morbidities, the most reliable predictive factors were cerebral vascular disease (p<0.001) and chronic renal failure (p=0.010). Among laboratory parameters, high C-reactive protein (p<0.001) and low albumin (p<0.001) levels were predictors of mortality in young adult patients with coronavirus disease 2019.

CONCLUSIONS

SpO2 at admission was the best predictor of mortality in young adult patients with coronavirus disease 2019. The mortality rate was increased by cerebral vascular disease and chronic renal failure. Also, high C-reactive protein and low albumin levels were predictive factors of mortality. Moreover, blood type O was associated with a higher mortality rate than the other types.

Impacts of Demographic and Clinical Characteristics on Disease Severity and Mortality in Patients with Confirmed COVID-19

Background

We investigated potential predictive factors for mortality and disease severity from demographic and clinical data, comorbidities, and laboratory findings in patients with confirmed COVID-19 who were consecutively admitted to our tertiary hospital.

Methods

In this retrospective, single-center, observational study, we enrolled consecutive 540 adult patients who had COVID-19 confirmed by a molecular method. Patients were categorized into three groups based on disease severity. Patients’ demographic and clinical characteristics, mortality rates, and mortality-associated factors were analyzed.

Results

The overall mortality rate was 4.3% (23/540). Disease severity was mild in 40.9% (n = 221), severe in 53.7% (n = 290), and critical in 5.4% (n = 29) of the patients. There were significant differences among groups in terms of median white blood cell (WBC), hemoglobin, neutrophil, lymphocyte, and thrombocyte counts, as well as C-reactive protein (CRP), procalcitonin, lactate dehydrogenase (LDH), creatinine, albumin, D-dimer, ferritin, troponin, and fibrinogen levels. Furthermore, there were significant differences between surviving and non-surviving patient groups in terms of median WBC, hemoglobin, neutrophil, and lymphocyte counts, as well as CRP, procalcitonin, LDH, creatinine, albumin, D-dimer, and ferritin levels. CRP level (odds ratio [OR]: 1.020, 95% confidence interval [CI]: 1.009–1.032; p < 0.001), and CURB-65 score (OR: 4.004, 95% CI: 1,288–12,447; p = 0.017) were independently associated with disease severity and mortality.

Conclusion

On admission, WBC, neutrophil, lymphocyte, and platelet counts can be used to predict disease severity in patients with COVID-19. CRP, ferritin, LDH, creatinine, troponin, D-dimer, fibrinogen, and albumin levels can also be used to predict disease severity in these patients. Finally, elevated CRP level and high CURB-65 score were predictors of disease severity and mortality.

Circulating furin, IL-6, and presepsin levels and disease severity in SARS-CoV-2-infected patients

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in a vast number of infections and deaths that deeply affect the world. When the virus encounters the host cell, it binds to angiotensin-converting enzyme 2, then the S protein of the virus is broken down by the transmembrane protease serine 2 with the help of furin, allowing the virus to enter the cell. The elevated inflammatory cytokines suggest that a cytokine storm, also known as cytokine release syndrome, may play a major role in the pathology of COVID-19. Therefore, the aim of this study is to investigate the relationship between circulating furin levels, disease severity, and inflammation in patients with SARS-CoV-2. A total of 52 SARS-CoV-2 patients and 36 healthy control participants were included in this study. SARS- CoV-2 patients were scored by the disease activity score. Serum furin, presepsin, and interleukin-6 (IL-6) levels were assessed using an enzyme-linked immunosorbent assay. The mean furin, presepsin, and IL-6 levels were significantly higher in the peripheral blood of SARS-CoV-2 compared to the controls (p < 0.001). There were close positive relationship between serum furin and IL-6, furin and presepsin, and furin and disease severity (r = 0.793, p < 0001; r = 0.521, p < 0.001; and r = 0,533, p < 0.001, respectively) in patients with SARS-CoV-2. These results suggest that furin may contribute to the exacerbation of SARS-CoV-2 infection and increased inflammation, and could be used as a predictor of disease severity in COVID-19 patients.

The value of the inferior vena cava ultrasound in the decision to hospitalise in patients with acute decompensated heart failure; the best sonographic measurement method?

OBJECTIVES

The primary aim of this study was to determine the value of the inferior vena cava (IVC) ultrasound in the decision to hospitalise acute decompensated heart failure (ADHF) patients. Our secondary aim was to find the most successful IVC measurement method in monitoring volume status.

METHODS

ADHF patients were accepted over a 1-year period in this study. Patients' vital signs, laboratory tests and IVC measurements measured by six methods (in B- and M-mode; maximum, minimum diameter and caval index) performed on an hourly basis were recorded. The presence of any statistically significant difference between the IVC measurement methods, laboratory tests and vital parameters between the hospitalised and discharged patients was calculated. ROC curves were produced in order to determine the ability of parameters to differentiate two groups. Spearman's correlation test was used to investigate correlation between the IVC measurement methods and patients' urine outputs.

RESULTS

A total of 71 patients were included in the study; 42 of these were hospitalised and 29 were discharged. Potassium, brain natriuretic peptide, respiration rate, urine output, maximum and minimum IVC diameters differed significantly between the two groups. Minimum IVC diameter measured in M-mode was identified as a weak marker with 65% sensitivity and 64% specificity (+PPV: 73%; -NPV:54%) for hospitalisation. Change in maximum IVC diameter measured in B-mode exhibited a high degree of correlation with change in body fluid (cc: 0.802).

CONCLUSION

IVC ultrasound may have a limited value in the decision to hospitalise ADHF patients. But Maximum IVC diameter may be an ideal method for monitoring hypervolemic patients' volume status.

CLINICAL TRIALS IDENTIFIER

NCT02725151.

An unusual presentation of Ewing sarcoma mimicking Guillain-Barré syndrome in a 17-years-old male

The management of a patient admitted to the emergency department with symptoms of Guillain-Barre syndrome (GBS), including paraplegia, who was subsequently diagnosed with Ewing sarcoma (ES) and spinal cord compression using MRI is discussed here. Pathological report confirmed the diagnosis of ES. The patient underwent immediate neurosurgery due to rapid progression of paraplegia.

Safety and efficacy of hydroxychloroquine in 152 outpatients with confirmed COVID-19: A pilot observational study

Purpose

We investigated the efficacy and safety of hydroxychloroquine for empirical treatment of outpatients with confirmed COVID-19.

Methods

In this prospective, single-center study, we enrolled ambulatory outpatients with COVID-19 confirmed by a molecular method who received hydroxychloroquine. The patients were divided into low- and moderate-risk groups based on the Tisdale risk score for drug-associated QT prolongation, and the QT interval was corrected for heart rate using the Bazett formula (QTc). The QTc interval was measured by electrocardiography both pretreatment (QTc1) and 4 h after the administration of hydroxychloroquine (QTc2). The difference between the QTc1 and QTc2 intervals was defined as the ΔQTc. The QTc1 and QTc2 intervals and ΔQTc values were compared between the two risk groups.

Results

The median and interquartile range (IQR) age of the patients was 47.0 (36.2–62) years, and there were 78 men and 74 women. The median (IQR) QTc1 interval lengthened from 425.0 (407.2–425.0) to 430.0 (QTc2; 412.0–443.0) milliseconds (ms). However, this was not considered an increased risk of ventricular tachycardia associated with a prolonged QTc interval requiring drug discontinuation, because none of the patients had a ΔQTc of >60 ms or a QTc2 of >500 ms. Moreover, the median (quartiles; minimum-maximum) ΔQTc value was higher in patients in the moderate-risk group than those in the low-risk group (10.0 [−4.0–18.0; −75.0–51.0] vs. 7.0 [−10.5–23.5; −53.0–59.0 ms]) (p = 0.996). Clinical improvement was noted in 91.4% of the patients, the exceptions being 13 patients who presented with non-serious adverse drug reactions or who had severe COVID-19 and were hospitalized. Adverse effects related to hydroxychloroquine were non-serious and occurred in 52.8% (n = 80) of the patients.

Conclusions

Our findings show that hydroxychloroquine is safe for COVID-19 and not associated with a risk of ventricular arrhythmia due to drug-induced QTc interval prolongation. Additionally, hydroxychloroquine was well tolerated, and there were no drug-related non-serious adverse events leading to treatment discontinuation in the majority of patients who were stable and did not require hospitalization.

Validity of Serum miRNA 93 and miRNA 191 to Reduce Unnecessary Computed Tomography in Patients With Mild Head Trauma

Background

Indication for the appropriate use of cranial computed tomography (CCT) in patients with mild head trauma (MHT) based on history and physical examination alone remains unclear. Recent studies have been reported that 90% of patients with MHT who undergo CCT under the present clinical decision rules have no clinically important brain injuries. We aimed to investigate whether peripheral blood expression of microRNA 93 (miR93) and microRNA 191 (miR191) in patients with MHT can predict the presence or absence of intracranial injury, reducing the unnecessary use of CCT.

Methods

Fifty-nine consecutive adult patients with isolated MHT undergoing CCT based on the clinical decision guidelines of the New Orleans criteria and 91 age- and sex-matched controls were enrolled in this prospective observational cohort study. Patients were divided into two groups: those without or with traumatic intracerebral or extracerebral lesions identified by CCT. Patients were further divided into two subgroups based on the presence or absence of traumatic parenchymal lesions defined as traumatic brain injury (TBI).

Results

Mean serum miR93 and miR191 levels differed significantly between study groups. Of the 79 patients investigated, 16 exhibited trauma-relevant lesions on CCT scan (CCT+). With a cut-off limit of 0.15, miR191 had an area under the curve value of 0.765 (0.640 - 0.889), with sensitivity of 68.1% and specificity of 68.8% in CCT+ patients. Compared to MHT patients without TBI, mean serum miR191 levels were markedly elevated in patients with TBI. However, miR93 levels did not exhibit significant changes in either group.

Conclusions

Circulating miRNA levels increased after MHT and differentiated patients with and without intracranial or extracranial lesions demonstrable on CCT. Adding the measurement of serum miRNAs particularly miR191 to the clinical decision rules for a CCT scan in patients with MHI could allow a reduction in scans.

A comparison of noninvasive methods for early detection of hemorrhage: Inferior vena cava ultrasonography and spectrophotometric hemoglobin levels

OBJECTIVES

Blood hemoglobin concentration measurements using a spectrophotometric method (SpHb), and inferior vena cava ultrasonography (IVC-US) are noninvasive methods used to follow-up hemorrhages. We compared their efficacy using voluntary blood donation as a model of moderate (approx. 500 mL) blood loss.

METHODS

In this prospective observational study enrolling blood-donor volunteers (BD) and matched controls, we recorded SpHb, IVC diameters, and vital signs. Changes in variables from baseline were compared between BD and controls using the paired t test and Wilcoxon signed rank test.

RESULTS

We included 118 subjects in the BD group and 95 healthy subjects in the control group. Changes in IVC maximum diameter, IVC minimum diameter, pulse rate, mean arterial pressure, pulse pressure, and shock index, but not in other variables, were significantly different in the BD and the control group (P < 0.05). IVCmax ≥1.1 mm yielded a 74% sensitivity and 77% specificity (PPV 79.8%, NPV 70.2%) in detecting early hemorrhage. With these cutoff values, IVCmax or PR reached a 90% sensitivity, while IVCmin and PR reached 98% specificity.

CONCLUSIONS

IVC ultrasound may be superior to SpHb in predicting blood loss and may be useful in addition to vital signs for its follow-up.

Bleeding Complications in Warfarin-Treated Patients Admitted to the Emergency Department

Background

Increased use of warfarin for the treatment and prophylaxis of many diseases has increased the frequency of adverse events. Emergency departments (EDs) are the first places where early interventions for bleeding and other complaints related to warfarin use are performed. This study assessed the characteristics of patients receiving warfarin and the risk factors for bleeding complication among those admitted to the ED.

Methods

Patients admitted to the ED for any reason other than trauma during a 1-year period were retrospectively reviewed. The study population consisted of 96 patients who had received warfarin and had an international normalized ratio (INR) ≥ 3. Patient demographics and medical history were recorded.

Results

The mean age of the patients (female, 52.1%) was 64.9 ± 14.5 years. Fatigue was the most common presenting complaint (61%). At least one major and/or minor bleeding event had occurred in 32 (33.3%) of the patients. Patients with (n = 32) and without (n = 64) bleeding complications did not significantly differ with respect to age, sex, reason for warfarin initiation, duration of warfarin use, concomitant diseases, and concurrent medications. There were also no significant differences in the distribution of patient admissions in terms of season at presentation, INR level, and weekly warfarin dose.

Conclusions

While the parameters evaluated in this study did not significantly differ among warfarin-treated patients, they may nonetheless pose a risk of bleeding. Further large-scale and long-term studies that take into account biological variation are required to precisely identify the risk factors for bleeding.

How much can synthetic cannabinoid damage the heart? A case of cardiogenic shock following resistant ventricular fibrillation after synthetic cannabinoid use

New substances are constantly being added to the content of synthetic cannabinoids (SCs). SCs can affect the cardiovascular system and cause hypotension and bradycardia, myocardial infarction, atrial fibrillation, prolonged QTc, and Mobitz type II atrioventricular block. However, no cases associated with ventricular fibrillation (VF) have been reported to date. We report a case of a 26-year-old male patient admitted to the emergency department due to altered consciousness after SC use and requiring prolonged cardiopulmonary resuscitation due to resistant VF and cardiogenic shock.

Usefulness of C1 esterase inhibitor protein concentrate in the management of hereditary angioedema of oropharyngeal tissue

Hereditary angioedema is an autosomal-dominant disorder caused by mutation of the gene encoding the C1 esterase inhibitor (C1-INH). It manifests as painless, nonpruritic, nonpitting episodic swelling of the subcutaneous tissues, gastrointestinal, and upper respiratory tracts in the absence of urticaria. An attack typically takes 24 h to peak and resolves over 48-72 h. The most serious manifestation is a laryngeal attack associated with upper airway swelling. The aim of this case report is to describe the lifesaving use of a novel C1-INH protein concentrate in a patient with mild-to-moderate dyspnea caused by swelling of the upper airway (larynx) and tongue.

A new side effect of synthetic cannabinoid use by the bucket (waterpipe) method: Acute respiratory distress syndrome (ARDS)

The use and content of synthetic canibinden (SCs) has been rapidly increased in the last decades. The complex content of these substances bring along a wide spectrum of side effects. In addition to the expected neuropsychological side effects of pleasure-inducing substances such as agitation, anxiety, panic attack and hallucinations, rare cases of cerebrovascular diseases, seizures, acute renal injury, myocardial infarction and chronic lung injury have also been previously reported. Here we report a 19-year -old male who was presented with acute respiratory distress syndrome (ARDS) within hours of inhaled SC use with the rarely preferred bucket method. There is limited information in the literature about pulmonary effects of SCs and we could not detect any other ARDS case that develoed within hours after consumption of SC with the bucket method.

Oxidative/antioxidative status, lymphocyte DNA damage, and urotensin-2 receptor level in patients with migraine attacks

BACKGROUND

The present study investigated the potential roles of plasma lymphocyte DNA damage, the urotensin-2 receptor (UTS2R), and oxidative changes in patients with varying degrees of migraine-related disability who were in the ictal phase and presented to our emergency department.

METHODS

This study enrolled 40 consecutive adult patients with migraine attack and 40 age- and sex-matched healthy controls. The same health care professional determined the headache-related disability of each patient's migraine attack using the Migraine Disability Assessment Scale (MIDAS); patients were divided into three groups based on MIDAS score. Plasma lymphocyte DNA damage; UTS2R, malondialdehyde (MDA), and catalase (CAT) levels; total oxidant status (TOS); total antioxidant status (TAS); and the oxidative stress index (OSI) were used as predictors of early oxidative changes.

RESULTS

Plasma lymphocyte DNA damage, TOS, MDA levels, and OSI values were significantly higher in patients with migraine compared to controls. Conversely, TAS and CAT and UTS2R levels were markedly lower in patients with migraine compared to controls. Comparisons of the patient groups by MIDAS score revealed significant differences in plasma lymphocyte DNA damage and CAT levels but no differences in TOS, MDA levels, OSI, TAS, or UTS2R levels. MIDAS scores were positively correlated with the degree of lymphocyte DNA damage, but neither of these factors was significantly related to CAT levels.

CONCLUSION

The present data suggest that lymphocyte DNA damage and changes in oxidative/antioxidative status may reflect an enhanced oxidative damage and an ineffective antioxidant defense system in migraineurs during headache attacks. In addition, lymphocyte DNA damage levels may be an indicator of the degree of migraine-related disability as assessed by MIDAS score.

Severe Blunt Perineal Trauma in Children: A Retrospective Analysis of 28 Patients

Purpose

The current study was designed to determine the common mechanisms of blunt perineal trauma (BPI) and associated injuries in paediatric patient. The initial management and outcome concerning such injuries are discussed.

Materials and methods

The hospital records of 28 paediatric patients who were treated surgically between April 2004 and November 2010 because of BPI were reviewed retrospectively. The initial clinical examination under conscious sedation (EUCS) in each patient was performed by both an experienced emergency physician and a paediatric surgeon to obtain a complete physical examination.

Results

Among the 28 paediatric patients, twenty-two girls and six boys, aged 2 to 12 years experienced BPI. Fall onto a rough surface was the main cause for BPI in 21 patients (75%) and the rest had a motor vehicle-pedestrian crash. Five patients had concomitant anal or rectal injuries. There were concomitant urinary tract injuries in eight patients of whom three had combined lacerations or contusions of the perineum and disruption of the posterior urethra. There was concomitant complete rupture of proximal urethra from bladder in one patient. The remaining 4 patients with urinary tract injuries suffered from periurethral lacerations. The fifteen patients without anorectal or urethral injuries had concomitant vaginal or vulvar lacerations.

Conclusion

All paediatric patients who sustained severe BPI should be checked for multi-system trauma and those undergone routine EUCS to evaluate the extent of concomitant injuries should pay particular attention to the anorectal and urogenital tracts. Primary repair of such injuries is often recommended as the initial treatment of choice.

Incomplete Cauda Equina Syndrome Presenting with Acute Urinary Retention in the Emergency Department

Cauda equina syndrome (CES) is a rare but serious neurosurgical emergency that can have devastating long-lasting neurologic consequences. CES caused by herniated lumbar discs is rare in the literature. We report an unusual case of incomplete CES due to lumbar disc herniation. The patient presented to our emergency department with acute onset of low back pain, saddle (perineal) anaesthesia, urinary retention and constipation without motor deficit or sciatica. Magnetic resonance imaging (MRI) revealed a large herniated disc originated from the L5-S1 disc space with compression of the cauda equina. This case illustrates that patients with CES accompanying a disc herniation may not have all the characteristic features of CES such as pain radiating to the legs or muscle weakness. We recommend that urgent MRI assessment should be performed in all patients who present with sudden onset of urinary symptoms in the context of lumbar back pain or loss of perineal sensation.

Opipramol Overdose Presented with Wide-Complex Tachycardia to the Emergency Department

Opipramol is an antidepressant and anxiolytic drug similar in structure to tricyclic antidepressants (TCAs) but it is primarily used for the treatment of generalized anxiety disorders. Unlike many TCAs, opipramol has no reuptake-inhibiting properties. Opipramol acts as a high affinity sigma receptor agonist. Opipramol acts as a low to moderate affinity antagonist for the dopamine-2 (D2), 5-hydroxtryptamine (5-HT2), histamine 1 (H1), histamine 2 (H2), and muscarinic acetylcholine receptors accounting for its antihistamine effects, and muscarinic anticholinergic properties. Here, we report a rare case of opipramol overdose case involving a 18-year-old woman, presenting to our emergency department (ED) with loss of consciousness and wide-complex tachycardia. A firm diagnosis of opipramol overdose was made on the basis of clinical, laboratory and electrocardiogram findings.

Demographic and clinical characteristics among Turkish homeless patients presenting to the emergency department

Objective

Since the homeless are at greater risk of encountering health problems than the general population, the reasons for and incidence of their presentations to emergency departments also vary. The purpose of this study was to determine the sociodemographic and clinical characteristics of Turkish homeless patients who brought to the emergency department by ambulance.

Materials and methods

The records of homeless adult patients brought to the ED by 112 emergency service ambulance teams over a 1-year period from January to December, 2014, were examined retrospectively.

Results

Thirty-six (21.56%) of the homeless patients enrolled in the study presented due to trauma, and 131 (78.44%) due to non-traumatic causes. One hundred thirty-seven (82.04%) of the total patient group were male. The mean age of the non-trauma patients was 47.3 ± 15.2 years (range, 18-81 years), and the mean age of the trauma patients was 36.9 ± 14.4 years (range, 18-63 years). The most common reason for presentation among patients presenting to the emergency department for non-trauma reasons was clouded consciousness (n = 39, 23.35%), followed by general impaired condition (n = 26, 15.57%), respiratory difficulty (n = 25 14.97%) and abdominal pain (n = 21, 12.57%). The most common reason for presentation among trauma cases was traffic accidents (n = 13, 7.78%), followed by sharp implement injury (n = 9, 5.39%). Four (2.4%) homeless patients died in the emergency department, three (%1.8) homeless patients discharged from the emergency department, and the remaining 160 (95.8%) were admitted to the hospital.

Conclusion

Homeless patients may present to the emergency department due to traumatic or non-traumatic causes. Admission levels are high among these patients, who may have many acute and chronic problems, and appropriate precautions must be taken in the management of these subjects in the emergency department.

A Novel Electrocardiographic Sign of an ST-Segment Elevation Myocardial Infarction-Equivalent: De Winter Syndrome

Patients with de Winter syndrome, also termed anterior ST-segment elevation myocardial infarction (STEMI)-equivalent, represent 2% of all patients with acute anterior myocardial infarctions admitted to emergency departments (EDs). STEMI-equivalents do not present with classical electrocardiogram (ECG) changes but exhibit a critical stenosis of the left anterior descending (LAD) coronary artery. This is under-recognized by clinicians and is therefore associated with high morbidity and mortality. Here, we report a rare case of a novel, typical, STEMI-equivalent ECG pattern without obvious ST-segment elevation in a 34-year-old female who presented to our ED with substantial chest pain and a large, acute, transmural anterior myocardial infarction caused by acute occlusion of the LAD coronary artery. However, she presented as a non-STEMI case. A definite diagnosis of de Winter syndrome was made on the basis of clinical and ECG findings.

A young puerperal woman presenting to emergency department with severe dyspnea

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with heart failure (HF) secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of HF is found. The symptoms and signs of this rare disorder mimic those of the physiological changes of pregnancy or other cardiovascular diseases. Consequently, its diagnosis is frequently delayed, which worsens an already poor prognosis. Here, we report a young adult who was diagnosed with PPCM, early, with the help of focused cardiac ultrasonography, performed after presenting to the emergency department with nonspecific respiratory complaints, including dyspnea and hemoptysis, which suggested at first pulmonary embolism.

A Rare Cause of Headache in the Emergency Department: Intraventricular Epidermoid Cyst Rupture With Hydrocephalus

Lateral intraventricular tumors are not frequently observed. Since these tumors grow linearly rather than exponentially, they grow gradually and thus do not cause mass effects and hydrocephalus. This study is the case report of a rare great volume left intraventricular epidermoid cyst rupture. The tumor was found to be associated with mass effect on neighboring structures and hydrocephalus.

The relationship between anemia and recurrence of ischemic stroke in patients with Trousseau's syndrome: A retrospective cross-sectional study

OBJECTIVES

The relationship between cancer and thrombosis was first recognized by the French internist Armand Trousseau in 1865. Trousseau's syndrome is a spectrum of symptoms that result from recurrent thromboembolism associated with cancer or malignancy-related hypercoagulability. In this study, we investigated whether demographics, clinical features, or laboratory findings were able to predict recurrent stroke episodes in patients with Trousseau's syndrome.

METHODS

In total, 178 adult patients were enrolled in this retrospective cross-sectional study. All patients had been admitted to the emergency room of our hospital between January 2011 and September 2014 and were diagnosed with acute ischemic stroke. Patients were divided into two groups: patients with malignancy (Trousseau's syndrome), and patients without malignancy.

RESULTS

There were several significant differences between the laboratory results of the two patient groups. For patients with Trousseau's, the hemoglobin levels for those with one stroke was 12.29 ± 1.81, while those in patients who had experienced more than one stroke was 10.94 ± 2.14 (p = 0.004).

CONCLUSIONS

Trousseau's syndrome is a cancer-associated coagulopathy associated with high morbidity and mortality rates. In this study, anemia was associated with increased stroke recurrence in patients with malignancy (Trousseau's syndrome).

Posterior reversible encephalopathy syndrome during the peripartum period: report of four cases and review of the literature

Posterior reversible encephalopathy syndrome (PRES) is a cliniconeuroradiologic disorder affecting the brain's occipital and parietal lobes characterized by altered mental status, seizures, headache and blurred vision. Eclampsia is one of the main causes of posterior reversible encephalopathy. We aimed to discuss here literature guided clinical and radiologic findings of four women who had experienced status epilepticus at peripartum period and diagnosed as PRES.

Mad honey intoxication mimicking acute coronary syndrome

Mad honey intoxication or grayanotoxin poisoning is caused by consumption of grayanotoxin-containing toxic honey produced from leaves and flowers of the Rhododendron family. Despite the rarity of intoxication cases, the correct diagnosis and treatment are required because of the significance of haemodynamic disturbance and confounding of symptoms for disease identification. We report herein a case of a patient with mad honey intoxication mimicking acute non-ST segment elevation myocardial infarction and review the pathophysiology and diagnostic considerations.

Hemostatic Efficacy of a Traditional Medicinal Plant Extract (Ankaferd Blood Stopper) in Bleeding Control

The aim of this study is to assess the in vivo hemostatic effect of Ankaferd Blood Stopper (ABS) on rats using a tail bleeding model. Wistar rats were randomized into 4 groups of 9 each: group 1, control, no pretreatment, irrigated with saline; group 2, no pretreatment, irrigated with ABS; group 3, control, heparin pretreatment, irrigated with saline; and group 4, heparin pretreatment, irrigated with ABS. To control bleeding, compressive dressings were placed after instilling 1 mL of either ABS or saline to the bleeding area. Without heparin pretreatment, ABS shortened hemostasis time by 1.57 minutes and reduced the amount of bleeding by 0.85 g. With heparin pretreatment, ABS shortened hemostasis time by 3.29 minutes and reduced the amount of bleeding by 1.32 g. The ABS was more effective than saline irrigation for treating tail tip bleeding in rats, with or without heparin pretreatment, while also using a compressive dressing.

Abdominal injuries related to bicycle accidents in children

PURPOSE

Bicycling is a well-liked sporting activity in which many children participate, and bicycle accidents are one of the most common causes of abdominal injuries in children. We evaluated the characteristics and outcomes of abdominal injuries due to bicycle accidents in children.

PATIENTS AND METHODS

This study was carried out retrospectively on children at the Department of Pediatric Surgery who were hospitalized for abdominal injury due to a bicycle accident, from 2008 to 2012. Abdominal injury-related bicycle accidents were evaluated with respect to patient characteristics, clinical presentation, management strategy, and outcome.

RESULTS

Fifty-nine patients were hospitalized for abdominal injuries related to a bicycle accident. The mean age of the patients was 11.48 ± 3.6 years. Most patients had an imprint of the handlebar edge on their abdomen. The most common abdominal organ injury due to a bicycle accident was laceration of the liver. Most patients were treated conservatively. Surgery was performed in 14 (24.1 %) patients. Hospital stay was 1-68 (mean 4.34 ± 11.6) days.

CONCLUSIONS

Abdominal injuries following a bicycle accident are frequent, serious, and preventable. Most patients were treated conservatively. Bicycle injuries can be prevented.